Saturday, December 18, 2010

I’d rather no one had to be married to enjoy full benefits of social and political life.

I hope today’s vote removes another barrier to social inclusion. It was a hard fight; this is a milestone.

Next year we’ll fight for immigrants to claim recognition, to trust women with decisions about their bodies, and for equitable, quality, universal affordable health care.

From Politico:

By SCOTT WONG
12/18/10 11:57 AM EST Updated: 12/18/10 3:52 PM EST

The Senate voted Saturday afternoon to repeal the ban on gays in the military, marking a major victory for gay rights and an end to the 17-year old “don’t ask, don’t tell” policy.

The bill now heads to President Barack Obama, who plans to sign it into law, overturning what repeal advocates believed was a discriminatory policy that unfairly ended the careers of thousands of gay members of the military over the years.

The 65-31 Senate vote marked a historic – and emotional – moment for the gay-rights movement and handed Obama a surprising political victory in the closing days of the 111th Congress. The legislation had been left for dead as recently as last week after Republicans in the Senate blocked efforts to advance it, yet on final passage, the bill won surprising support from eight Republicans.

The repeal, which would not take effect immediately, ushers in a major cultural shift for a military that has operated under the “don’t ask, don’t tell” policy since the first year of Bill Clinton’s presidency.

The Senate vote capped months of uncertainty about whether Congress or the federal courts, where gay-rights advocates are fighting the ban, would act first to repeal the policy.

The real drama had already come a few hours earlier when the repeal bill cleared a crucial procedural hurdle. The 63-33 cloture vote was three more than needed to beat back a Republican filibuster.

With support from all but one member of the Democratic caucus and help from seven Republicans, the bill overcame the 60-vote threshold required to move forward.

The Republican senators voting “yes” with the Democrats were Richard Burr of North Carolina, Mark Kirk of Illinois, John Ensign of Nevada, Scott Brown of Massachusetts, George Voinovich of Ohio, Lisa Murkowski of Alaska – and Olympia Snowe and Susan Collins, both of Maine. Burr, Ensign and Kirk were late surprises, bucking their party on the historic vote.

West Virginia Sen. Joe Manchin, who previously stated he opposes repeal, was the only Democrat to miss the vote, apparently because of a family “holiday gathering,” his spokeswoman said.

President Barack Obama called the procedural vote an “historic step” toward ending a discriminatory policy that weakens America’s national security and violates the ideals troops risk their lives to defend.

“By ending ‘Don’t Ask, Don’t Tell,’ no longer will our nation be denied the service of thousands of patriotic Americans forced to leave the military, despite years of exemplary performance, because they happen to be gay,” Obama said in a statement. “And no longer will many thousands more be asked to live a lie in order to serve the country they love.”

The repeal measure, passed by the Senate Saturday, already cleared the Democratic-controlled House this week along a mostly party-line 250-175 vote. It now goes directly to the president for his promised signature.

The repeal, however, wouldn’t take effect immediately. Obama, Gates and Mullen would have to certify to Congress that they have reviewed the Pentagon report on the impacts of repeal, that the Defense Department is prepared to implement repeal and that doing so would not harm military readiness, troop morale, and recruiting and retention.

The policy would be repealed 60 days after the president submits the document.

Sunday, November 14, 2010

Thank you so much for this award. It is a deep honor to carry on the historic and inspiring work of Dr. Paul Cornely, a lifelong fighter for social justice. Upon his death in 2002, the Washington Post recalled his outstanding lifetime in public health. He was the first black president of the American Public Health Association (1970), the first black person to earn a doctorate in public health (1934), and a founder and first president of the D.C. Public Health Association in 1963 (now the Metropolitan Washington Public Health Association.) Among his landmark struggles was the fight to eliminate segregated health care.

It is especially meaningful to celebrate the traditions those of us gathered together tonight share.

The APHA annual meeting usually follows just on our national elections, and as a result we've shared many historic moments together.

We were together on the eve of the Bush presidency in 2000, and again when we led him to fire Donald Rumsfeld in 2006.
We were together when we elected Barack Obama in 2008.
And this week, of course, the San Francisco Giants have won the World Series for the first time in decades - against the Texas Rangers, I might add.

It has been a difficult week in some other respects but we are so lucky in so many ways - that we do still have the motivation, the means and the wherewithal to speak up for what we believe in.

And especially that we have each other to come together and share it with.

The corporate assault on politics is not new.

There are real historians here so I'll just talk from two of my personal sources of information - my parents and the movies.

I remember my parents telling me about Glenn Beck's precursor, the hate-spewing Father Coughlin, an anti-Semitic, pro Nazi demagogue who dominated the radio airwaves in the 1930s.

And I've been watching re-runs lately of "Mr Smith Goes to Washington." Freshly minted Senator Jimmy Stewart tries to stop a local wheeler dealer from diverting federal funds to build a dam on his property. Jimmy Stewart did everything he could muster. He filibustered on the floor of the Senate to marshal the local press back home - Mr Big confiscated all the newspapers and paid off the radio announcers. Jimmy mobilized the Boy Scouts to hand out fliers, and Mr. Big's goons beat up the Boy Scouts! But he kept at it and kept at it, til Senator Claude Rains couldn't take it any more and handed Jimmy his victory.

Their techniques are more sophisticated today. But the goal is always the same - to keep us ignorant and quiet, so the bullies of the world can get their way.

I think we've had more than one victory this year. We passed health care reform, after a century of failure. It is pock-marked, bullet-ridden and precarious, but it does two things at the heart of the single payer system we are going to win:

It expands the role of government in assuring coverage and payment for health care - something we must start talking about, positively and effectively.

And it targets administrative waste and reform of the delivery system.

These fundamental reforms are in addition to the immediate benefits I hear about every day, in the work of the EQUAL Health Network to educate about, implement and improve the new law, the immediate reason for this honor tonight.

Nothing could give me greater pleasure than to have the chance to share this room with the many of you who've stood here before me, and forged our identity as people who will speak truth to power - and will bend it!

Friday, October 15, 2010

Many are mad as hell this election season, including some progressives. Absent the funding of the madly rich and insanely right-wing Koch brothers, what are we to do?

For one thing, take a sober look at the policy and politics associated with the Affordable Care Act.

This is not the single payer system many staunch health care reform advocates - including me - preferred, but lacked the power to enact. As we continue the campaign for a single payer, it is essential to recognize, vigorously defend and advance the victories we achieved in the Affordable Care Act, in order to preserve the gains for people in need and also to shore up the valuable activists, and activism, we will need for what is going to be a long haul ahead.

Here's what the ACA accomplishes, what single payer systems do, why we're absolutely right to continue to advocate for them, and how we can shape policy to get there from here.

What does the ACA accomplish? The U.S. health care system will do a better job of treating illness and improving health at an affordable cost. The Medicare Trust Fund will be solvent for an additional 12 years, through 2029. There are substantial improvements for lower and middle income people, and immediate benefits for women, younger people, seniors and small businesses. Importantly, the ACA creates policy space to continue efforts to cover everyone while controlling costs, goals that are popular with the public. It accomplishes these objectives in part by imposing new progressive taxes and fees on the wealthiest 2% of the population and on employers.

Politically, the ACA opens opportunities to challenge corporate power at the national level, in the formation of extensive regulations. It throws some leverage to the states, which progressives can use to advance our goals of equitable, quality, universal, affordable health care.

The law includes compromises that call out for revision, particularly on affordability, and on coverage for immigrants and for reproductive health care. And the political process that got us here will be grist for analysis for decades to come.

But it is just not true, as some have characterized it, that the law is primarily a victory for business as usual by the insurance industry. Furthermore, the fight to undermine and defeat the law unquestionably empowers and invigorates the most predatory anti-government political and financial interests in the country. Since the facts don't serve their agenda - to profit by destabilizing our social and financial security, including dismantling Medicare - they rely on hyperbole and distortion to mobilize the public's complicity in opposing our own real best interests. In contrast, we can and must remain critical while carefully examining sweeping generalizations that don't fit.

Single Payer: Getting There from Here

Single payer systems funnel all payments for health care to one collection point - usually a state or national government. This single payer then pays all the health care providers: doctors, hospitals, drug companies. There is overwhelming evidence that single payer systems are more cost-efficient and affordable, along with their many benefits for equity and quality of care.

This is different from our current system in at least two ways that are key to controlling health care costs.

• First, it is administratively efficient. It eliminates the middleman: the proliferation of private insurance companies that take a bite out of every health care dollar for the administrative service of paying the bills. These insurance companies, both for-profit and non-profit, now rake off about 30% or more of our insurance premiums, using ploys that at the same time restrict access to necessary health care and inflict great suffering on ailing humanity. They also add to the administrative burdens of doctors and hospitals.

Largely for these reasons, single payer proposals are fiercely attacked, maligned and misrepresented and in all manner just blocked in the halls of power by the industry, which profits nicely from this mess.

The state and federal governments are now writing the rules for implementing the Affordable Care Act. Advocates can help to shape these rules to get us closer to administrative efficiency, and to expand the public sector's purview over prices. Some examples:

• In 2014, new insurance Exchanges will standardize health insurance plans. People who buy insurance now as individuals or in small groups will be grouped into much larger pools, sharply reducing cost-shifting. Advocates have the opportunity to craft and support state laws implementing the exchanges that can push limits on standardizing health plans and require financial transparency.

• The law sharply expands the number of people covered by public sector health plans. For the first time Medicaid will cover everyone under 133% of the federal poverty level, regardless of health status. State governments already do negotiate drug prices under Medicaid, in which enrollment will grow by almost half by 2014. State laws to adopt a public option would further expand the number of people who receive health care either paid for or provided directly by the public sector.

• There are numerous opportunities to regulate, review and otherwise limit premiums, depending on the rules adopted by HHS, and state implementation laws. The current policy debate on how to define and enforce the Medical Loss Ratio is an important example.

• The law also draws on the public's control over Medicare to address some of the underlying drivers of increasing health costs through new measures such as comparative effectiveness research and payment reforms to encourage more cost-effective delivery systems. It also expands primary care and public health.

• Finally, as soon as 2017 - maybe sooner - there is a defined process for states to prepare for and enact alternative systems, including single payer.

The corporate media surround us with messages - and messengers - that exhort us to succumb to cynicism (nothing will ever work, they'll always sell us out). Voluntarily taking ourselves out of the real health care fights of the day is tantamount to capitulation. Effective strategies for building the power we need will require and emerge from engagement as well as resistance. Advocates can rebuild public awareness and momentum for single payer systems, and at the same time support legislation and regulations that maximize the progressive aspects of the ACA. If done well, our work on the ACA will build the pathways we need to a single payer system.

Monday, October 11, 2010

The Affordable Care Act (ACA) has created a new system of health insurance exchanges. States can design and implement the exchanges to offer new opportunities for access to affordable, accountable health insurance. California’s law is the first in the nation..

Under the federal ACA, exchanges will open in 2014 to offer standardized insurance plans to individuals and small businesses, with subsidies available to people earning up to 400% of the federal poverty level. The California law creates a 5- member governing body with two important features. First, it must “take into consideration the cultural, ethnic, and geographical diversity of the state so that the board’s composition reflects the communities of California.” Secondly, its strong conflict of interest provisions exclude participation by active agents of the insurance and health care industries.

In a key provision for affordability, the state will have the right to engage in “selective contracting” with insurance plans, meaning it will be able to negotiate on premium rates. In addition, it has the right to “require carriers to offer additional products within each of” the five levels of coverage specified by the ACA. These could conceivably refer to supplementary dental plans.

The exchanges for individuals and small employers are initially separate. They could be united in the future, pending a study due by 2018.

The exchange must be self-supporting, after repaying an initial loan for administrative start-up, although there is a prospect for General Fund support. Critics have noted that this funding limitation could hamper the exchange’s viability.

The law includes other important features. It requires coordination with existing health programs. The exchange must provide “oral interpretation services in any language for individuals seeking coverage through the Exchange and makes available a toll-free telephone number for the hearing and speech impaired.” And, “The board shall ensure that written information made available by the Exchange is presented in a plainly worded, easily understandable format and made available in prevalent languages.” Further, the Board must “consult with stakeholders relevant to carrying out” its activities, including “health care consumers who are enrolled in health plans, individuals and entities with experience in facilitating enrollment in health plans, representatives of small businesses and self-employed individuals, the State Medi-Cal Director, and advocates for enrolling hard-to-reach populations.”

Friday, September 17, 2010

Today is the deadline for comments on interim federal regulations on what constitutes a preventive health care service. This is relevant because under the new health care reform law, preventive health care services are to be provided without co-payments and deductibles. Which somehow raises the apparently puzzling question as to whether contraception (defined as methods to prevent pregnancy) is preventive.

Or related to health.

The Obama administration isn't sure about this, and so has asked the Institute of Medicine to study it. This isn't really the question.

The question is: Do men have sex?

Based on substantial empirical evidence, though no new primary research, I assert: They do.

I further assert (and this is recent news as of the last few thousand years) that there are statistically zero pregnancies that occur without the involvement of sperm. This is most commonly supplied by a man known to the prospective mother, but could be supplied through artificial insemination.There were about 4.2 million U.S.births in 2009.

I appreciate that it is women who become pregnant. I appreciate and am an active participant in the women's health movement. There are health conditions that actually occur only in women (cervical cancer) or mostly in women (breast cancer), and gender-related factors that determine female well-being, life chances and longevity.

But I submit that contraception, conception and pregnancy are biological events that involve both males and females; and usually, not to be coy about it, sex.

Now here is how the new regulations will work: Every other on-its-face preventive service will be provided without extra cost-sharing. Starting on Sept. 23.

The Department of Health and Human Services was so eager to get this done that it is issuing interim regulations, meaning we can still submit comments on proposed regulations but meanwhile the interim regs will go into effect. But the Institute of Medicine is going to have to determine whether contraception really is preventive, and related to health, and a service. That will take till August 2011. Then, assuming that they do so affirmatively determine, it will be about another year before you get your IUD, birth control pills -- or vasectomy -- without an additional copay.

We in the women's health movement are going about this all wrong. Contraception is not about protecting women, at least not alone. Contraception is about the rights of men to have sex. In fact, contraception should be the corollary of every prescription for Viagra. In fact, that was the argument Jackie Speier used successfully, when she was a state senator, to get contraception covered by Califormia insurance plans.

Men, whatever else you think about health care reform, I think most of you know and like your female partners. (And LGBT adoptive and assisted technology parents generally feel the same.) You share, at least, the financial and emotional expenses of child-rearing, to say nothing of pregnancy; and if you don't, well, we have laws about that, too. So drop a note by clicking here to the EQUAL Health Network, and we'll let HHS know you know where babies come from. They need your help. You're so big and strong.

Wednesday, August 25, 2010

Should insurance companies be able to get off the hook for paying rebates to customers, who may believe their company is unfairly denying them specific medical care in order to save money, by virtue of engaging in health promotion campaigns?

Last week the National Association of Insurance Commissioners issued proposed rules for measuring the Medical Loss Ratio (MLR), a key instrument for controlling health insurance premiums. The MLR is the 80-85% of premiums that the new health care reform law requires insurance companies to spend on medical care, or improvements to the quality of care, as opposed to administration. Companies that fail to meet that test must give suscribers a rebate. The usually out-gunned consumer representatives at the NAIC supported the state insurance commissioners' vote to adopt the proposed rules unanimously, claiming a victory against insurance industry lobbyists.

But a key provision that slipped through threatens both the effectiveness of the MLR, and the integrity of public health departments. The U.S. Department of Health and Human Services (HHS) is backing a late amendment that would allow insurance companies to count their collaborations with public health departments as quality improvements.

What this means: Partnerships between private, for-profit health insurance companies and cash-strapped public health departments would be counted as part of the expenditures of your premium dollars to improve your health.

The key question is this: Should insurance companies be able to get off the hook for paying rebates to customers, who may believe their company is unfairly denying them specific medical care in order to save money, by virtue of engaging in health promotion campaigns?

Even assuming you like the idea of entrusting health promotion campaigns to your health insurance company, is the MLR a remotely suitable mechanism for encouraging them to engage in these canpaigns?

This is a classic mismatch of policy priorities. The MLR is meant to compel your insurance company to direct your premiums to pay for your health care. If your premium dollars are going to programs that benefit any non-subscriber. it shouldn't count against your right to a rebate. On the other hand, public health departments are meant to use your tax dollars to improve the health of your community. There are simply no grounds to divert public health department efforts to serve subscibers to a particular health plan.

There aren't a lot of these partnerships now - at least not legitimate ones. Most often they take the form of marketing campaigns that happen to focus on public health issues such as smoking cessation. If this rule stands, we can likely look forward to increasing insurance industry incursions into public health territory. So what? At least 3 things: 1. Premium dollars will be further frittered away on marketing campaigns re-dubbed as "health awareness." 2. Real public health department initiatives, and funding for same, will be undermined as already scarce public health staff are diverted to determining whether particular insurance company campaigns are legitimate or not. 3. Smoking cessation campaigns, for exanple, can help insurance companies identify and then cherry-pick customers, either excluding smokers from coverage, or charging them more (the excess charges remain legal even after new rules take effect in 2014).

Interestingly, the insurance industry is also lobbying not to count investment income, or the taxes they pay on investment income, as, well, income, for purposes of calclating the MLR. Those are the taxes that they should be paying to support our state and local health departments.

HHS has to "certify" the NAIC's recommendations before they take effect. The EQUAL Health Network says this one should get a recall.

Thursday, August 12, 2010

The still-fragile Affordable Care Act (ACA) gives the public a fighting chance at reining in health insurance premiums. But we’re going to have to wrestle with the insurance industry every step of the way. As the National Association of Insurance Commissioners (NAIC) convenes in Seattle today, the public has the imperative to stick up for ourselves. Here’s what’s at stake in this round.

Starting in September, health insurance plans are required to spend at least 80-85% of the premium we pay them on actual health care. Executive bonuses, administration, marketing and profits are limited to the other 15% (in large plans) to 20% (in small plans). This is supposed to incentivize the insurance industry to operate efficiently and to negotiate assertively with health care providers. rather than simply passing on cost increases to consumers.

The $2.5 trillion dollar question is this: how do you define actual health care? The Secretary of Health and Human Services defines this figure, known as the Medical Loss Ratio (MLR), after consulting with the NAIC. And the insurance industry has not been shy.

The insurance industry is asking the NAIC to define the MLR to its advantage, by counting marketing programs, including those with public health themes, as medical expenses, rather than the administrative expenses they clearly are.

The aims of the relevant section of the law (Sec. 2718) - low cost care that offers value to consumers – conflict with the financial imperatives of the health insurance industry, to maximize profits and returns to shareholders, as well as administration, including executive compensation. Proposals by the insurance industry call for calculating the MLR in a way that will frustrate the aims of the law. The MLR is a ratio, with all medical claims (in the numerator), divided by total premiums (in the denominator). A high MLR means that the insurance company is spending a relatively higher share of premium income on its members' medical care and less for administration and profit. A low MLR means that the insurance company is returning less in medical care benefits to its members while retaining more for executives and shareholders; this can also signal a solid opportunity for investors.

To fairly achieve an 85% MLR, a company would have to show that the amount spent on medical claims (in the numerator) is high relative to premiums. But companies can frustrate the intent of the law by defining medical claims to include other expenses, including expenses typically considered part of administration.

The Senate Commerce Committee has documented that, "At least one company, WellPoint, has already ‘reclassified’ more than half a billion dollars of administrative expenses as medical expenses, and a leading industry analyst recently released a report explaining how the new law gives for-profit insurers a powerful new incentive to ‘MLR shift’ their previously identified administrative expenses."

The ACA standard for including expenditures for non-clinical care as a medical expense (that is, in the numerator) is that it must "improve health care quality." It’s hard to imagine this test will be met by the few occasions of insurance companies’ co-sponsoring visible public health events, nor do they justify skewing the MLR in ways that would raise premiums, or requiring the additional administrative effort to determine whether or not it is in itself an administrative or medical expense.

In our letter to the HHS and NAIC, the EQUAL Health Network urged, "The NAIC and HHS should discourage efforts by insurance companies to create and benefit from insubstantial programs that masquerade as clinical treatments. These programs should be properly counted as the administrative expenses that they are. Otherwise, a proliferation of such programs, if regarded as clinical care, would have the exact opposite of the intended effect of the measure: it would cause health care expenditures to balloon, and dilute value for consumers."

What About Their Investments?

The ACA standard applies only to insurers' premium revenues. Yet patients and payors should be equally concerned about how an insurer uses income from its investment of the sums it extracted from previous years’ patient premiums. A more appropriate standard would measure the share of insurers' total revenues devoted to care, as some analysts have urged.

NAIC committees have been working largely outside of the public’s view to draft standards. In our letter, the EQUAL Health Network urged, "It is vital that rate review and other pressures be strong enough to prevent insurers from simply raising premiums in order to offset the limit on their administration/profit share. It will also be important to create an ongoing public process to set and review the initial regulations which are required to begin in September, 2010. Public comment on this system's achievements and limitations will provide assessments of the system's success, and offer the groundwork for constructive and equitable adjustments to the rules."

Saturday, July 24, 2010

Progressives failed to prevail on important policy debates during health care reform, including on the public option. There is no doubt that this was a central victory for the insurance industry. The retreat into magical thinking holds that we can measure the how the industry got its way by measuring campaign contributions, and drawing totally unfounded conclusions about the role of indivduals like Liz Fowler and Max Baucus. The record does not support this simplistic though appealing analysis:

According to the Center for Responsive Politics (opensecrets.org), the largest health insurance PACs gave more money in 2008 to Henry Waxman than to Max Baucus (and it wasn't much, at that). Waxman voted yes on the public option; Baucus voted no.

They gave more to the House, which voted yes on the public option, than to the Senate, which voted no.

PACs:
Wellpoint Inc Contributions to Federal Candidates, 2008

House
Total to Democrats: $152,000
Total to Republicans: $260,100

Senate
Total to Democrats: $48,900
Total to Republicans: $98,500

UnitedHealth Group Contributions to Federal Candidates, 2008

House
Total to Democrats: $138,700
Total to Republicans: $100,500

Senate
Total to Democrats: $71,500
Total to Republicans: $58,300

Henry Waxman: $3,000 - yes on public option

Max Baucus: $1,500 - no on public option

What's my analysis? Over time we'll sort out who did what to whom. It's comforting and titillating to believe that there were a few culprits, and that we've found the main one in Liz. We could note alternatively many more profound truths about how disconnected much of the country is from advocacy at the national level, a pattern that persists, and which we can affect. Retreating into Fox News-style sensationalism is not a substitute for analysis.

Tuesday, July 20, 2010

Post-script:
This time they did not have to do it. There was no Ben Nelson, no Joe Lieberman. No applicable federal law. Not even much to lose. The Obama Administration chose to deny abortion funding in the new high risk pools, due to start next month. These enrollees will be among the most vulnerable women in the US: uninsured, with an existing health condition. The high risk pools were not already subject to the infamous Executive Order banning use of federal funds for abortion through the health insurance exchanges (due to start in 2014). The Executive Order was part of the price for heath reform. Well, ok, something to be fixed down the road. The road seems to have come to our door.

Why did the Administration extend this bad ruling to the high risk pools? Anti-choice groups went viral about the President betraying them if he did not extend to the already unconscionable Executive Oder to the high risk pools. Who thanked him? The Catholic bishops.

We have allowed abortion to become toxic. A procedure experienced by at least a third of women during our lives has been stigmatized. It is not enough to appoint and elect many fine, smart, progressive women – and pro-choice men – to government. They need, and we need, militant mobilized advocacy for reproductive choice and justice.

The Department of Health and Human Services has released an announcement stating that abortion coverage may only be obtained in the new high risk pool plans in cases of rape or incest, or where the life of the woman would be endangered. This wording mirrors the restrictions articulated in the Hyde Amendments to certain appropriations bills. (See below for full text of announcement)

As federal law currently stands, there are no restrictions placed upon federal or state money regarding abortion coverage in the Pre-existing Condition Insurance Plans (PCIP). The PCIPs are temporary insurance pools to provide insurance coverage to those deemed “high risk,” meaning the individual has some kind of pre-existing condition.

Because no law specifically addresses PCIPs and abortion coverage, the HHS statement would create a new sphere of abortion restrictions, undermining women’s reproductive autonomy.

The EQUAL Health Network believes these new restrictions are a response to pressure from anti-choice activist groups, and are unwarranted.

None of the current federal abortion restrictions that are in place apply to the PCIPs. The Hyde Amendment, which restricts abortion coverage to rape or incest, or where the life of the woman is in danger, only applies to funding appropriated through the Departments of Labor and Health and Human Services, including Medicaid. The appropriations for the Federal Employee Health Benefits Plan also restrict abortion coverage, but this clearly does not apply to the PCIPs.

In addition to nonexistent precedent for this action in prior federal law, there is no precedent in the Patient Protection and Affordable Acre Act (PPACA). The Nelson Amendment, adopted in the new law, only applies to plans obtained in the healthcare exchanges, which will not be active until 2014. Lastly, the Executive Order that the President signed regarding abortion coverage through PPACA gives no indication that it was meant to apply to more than the healthcare exchanges and community health centers.

The abortion coverage restrictions placed on the PCIPs is reminiscent of the Stupak Amendment first seen in the House version of PPACA, but later removed. The Stupak restrictions would have forbidden use of any funds, even those procured privately or through states, to provide abortion coverage to individuals participating in the PCIPs.

Jessica Arons from the Center of American Progress
http://www.rhrealitycheck.org/blog/2010/07/15/obama-administration-applies-stupak-amendment-high-risk-pools

Text of HHS announcement:
As is the case with FEHB plans currently, and with the Affordable Care Act and the President’s related Executive Order more generally, in Pennsylvania and in all other states abortions will not be covered in the Pre-existing Condition Insurance Plan (PCIB) except in the cases of rape or incest, or where the life of the woman would be endangered.

Our policy is the same for both state and federally-run PCIP programs. We will reiterate this policy in guidance to those running the Pre-existing Condition Insurance Plan at both the state and federal levels. The contracts to operate the Pre-existing Condition Insurance Plan include a requirement to follow all federal laws and guidance.

Sunday, July 11, 2010

It's too bad the governors worrying that challenging the Arizona law will hurt their chances in the upcoming election can't find the NYT article on February 18, 2007 by Louis Uchitelle, explaining precisely how NAFTA has driven Mexicans out of their own fields and factories and into the U.S.' Years later, all the misguided policy gurus at the Peterson Institiute can say is "oops," (and let's dismantle Social Security while we're at it). Concerned about creating jobs and stemming the deficit? Reverse NAFTA and CAFTA, and invest in education and social programs. We need leaders who will follow the President's example, and exhibit leadership.

Here's the news from the NY Times, over 3 years ago.

February 18, 2007
The Nation
Nafta Should Have Stopped Illegal Immigration, Right?
By LOUIS UCHITELLE
THE North American Free Trade Agreement, enacted by Congress 14 years ago, held out an alluring promise: the agreement would reduce illegal immigration from Mexico. Mexicans, the argument went, would enjoy the prosperity and employment that the trade agreement would undoubtedly generate — and not feel the need to cross the border into the United States.

But today the number of illegal migrants has only continued to rise. Why didn’t Nafta curb this immigration? The answer is complicated, of course. But a major factor lies in the assumptions made in drafting the trade agreement, assumptions about the way governments would behave (that is, rationally) and the way markets would respond (rationally, as well).

Neither happened, yet Nafta remains the model for trade agreements with developing Latin countries, including the Central American Free Trade Agreement, passed by Congress in 2005. Three more Nafta-like agreements are now pending in Congress — with Panama, Columbia and Peru.

When Nafta finally became a reality, on Jan. 1, 1994, American investment flooded into Mexico, mostly to finance factories that manufacture automobiles, appliances, TV sets, apparel and the like. The expectation was that the Mexican government would do its part by investing billions of dollars in roads, schooling, sanitation, housing and other needs to accommodate the new factories as they spread through the country.

It was more than an expectation. Many Mexican officials in the government of President Carlos Salinas de Gortari assured the Clinton administration that the investment would take place, and believed it themselves, said Gary Hufbauer, a senior fellow at the Peter G. Peterson Institute for International Economics in Washington who campaigned for Nafta in the early 1990s.

“It just did not happen,” he said.

Absent that investment, foreign factories congregated in the north, within 300 miles of the American border, where some infrastructure already existed. “Monterrey is quite good,” Mr. Hufbauer said, “but in a lot of other cities the infrastructure is terrible, not even enough running water or electricity in poor neighborhoods. People get temporary jobs, but that is all.”

Meanwhile, Mexican manufacturers, once protected by tariffs on a host of products, were driven out of business as less expensive, higher quality merchandise flowed into the country. Later, China, with its even-cheaper labor, added to the pressure, luring away manufacturers and jobs.

Indeed, despite the influx of foreign-owned factories, total manufacturing employment in Mexico declined to 3.5 million by 2004 from a high of 4.1 million in 2000, according to a calculation of Robert A. Blecker, an American University economist.

As relatively well-paying jobs disappeared, Mexico’s average wage for production workers, already low, fell further behind the average hourly pay of production workers in the United States, and Mexicans responded by migrating.

“The main thing that would have stemmed the flow of people across the border was a rapid increase in wages in Mexico,” said Dani Rodrik, an economist and trade specialist at Harvard’s John F. Kennedy School of Government. “And that certainly has not happened.”

Something similar occurred in agriculture. The assumption was that tens of thousands of farmers who cultivated corn would act “rationally” and continue farming, even as less expensive corn imported from the United States flooded the market. The farmers, it was assumed, would switch to growing strawberries and vegetables — with some help from foreign investment — and then export these crops to the United States. Instead, the farmers exported themselves, partly because the Mexican government decided to reduce tariffs on corn even faster than Nafta required, according to Philip Martin, an agricultural economist at the University of California, Davis.

“We understood that the transition from corn to strawberries would not be smooth,” Professor Martin said. “But we did not think there would be almost no transition.”

A financial crisis also dashed expectations. One expectation was that the Mexican economy, driven by Nafta, would grow rapidly, generating jobs and keeping Mexicans home. The peso crisis of 1994-95, however, provoked a steep recession, and while there was some big growth later, the average annual growth rate over Nafta’s lifetime has been less than 3 percent.

The financial crisis struck just months after Nafta came into existence, undermining, early on, the Mexican government’s ability to spend money on roads, education and other necessary government functions.

“We underestimated Mexico’s deficits in physical and human infrastructure,” said J. Bradford DeLong, an economist at the University of California, Berkeley, and a Treasury official in the Clinton administration.

But, he says, without Nafta the migration would have been even greater. For instance, he says, there would not have been as much investment in the north of the country.

Finally, the steady flow of Mexicans to the United States has produced a momentum of its own — what Jeffrey Passel, a demographer at the Pew Hispanic Institute, calls a “network effect,” in which young Mexicans travel to the United States in growing numbers to join the growing number of family members already here.

The upshot is that Mexican migration to the United States has risen to 500,000 a year from less than 400,000 in the early 1990s, before Nafta, Mr. Passel estimates. Roughly 80 percent to 85 percent of immigrants are here illegally, he says.

The peso crisis, recession, the network effect — their impact may have been beyond anyone’s control, but not the assumptions about how the market and the government would act.

“We have indeed had one disappointment after another on this score,” Mr. Rodrik said, noting that the same assumption about government spending is part and parcel of the agreements, now before Congress, with Columbia, Peru and Panama.

While there is opposition to these proposals, it is mainly from Democrats who want a better safety net for American workers who might be hurt.

The European Union, in contrast, assumes little about government spending on the part of economically weaker nations joining it. The union itself has hugely subsidized the improved services needed by entering countries like Portugal, Spain, Greece and Poland, rather than leave financing to the relatively meager resources of entering countries.

The money is used not only for public investment, Mr. Rodrik noted, but also to subsidize companies setting up operations in the new countries and to support government budgets.

“I am not saying Nafta was a bad agreement,” Mr. Rodrik said. “But more than a trade agreement is required for countries to converge economically. And Nafta has been viewed as a shortcut to convergence without having to do all the other stuff.”

Friday, June 25, 2010

The annual Commonwealth Fund study has found once again that the U.S. stacks up last in five measures of healthcare -- quality, efficiency, access to care, equity and healthy lives, compared with Britain, Canada, Germany, Netherlands, Australia and New Zealand. All these countries spend a fraction on health care compared with the U.S.

The new health reform law could address some of these deficiencies. But the findings are under attack from defenders of the status quo who claim in part that the problem is not in our health care system, but in our poverty rate.

Countries do have to do a number of things right to actually improve health:
1. Cover everyone for ready access to health care, to nip problems before they escalate, and to control chronic conditions with medicines or lifestyle changes.
2. Treat acute cases by well trained teams that have access to information about how to diagnose and treat hospitalized patients safely, and have the financial and organizational incentives to do so.
3. Reduce inequities that aggravate poor health, particularly economic differences between rich and poor, and social discrimination based on race, gender, sexuality, disability, etc. The stress of relative powerlessness takes a physical toll and compounds the lack of resources that can buy healthy circumstances: Violence-free neighborhoods where outdoor exercise is safe, healthy food and time to prepare it, spending on social programs like education and income support, information about sexual and physical health, as well as good health care.
4. Finally, it should be affordable so that everyone can use it, including those who need it most. This usually means authorizing the government to play a major role in negotiating prices with the health care industry.

U.S. is deplorably deficient in these areas of performance. And it doesn't all happen in lower-income states like Mississippi. Access is unquestionably a function in part of coverage and is equally wretched in California (where policy has been held hostage for decades to arcane but effective rules against social spending) as in the south. Preventable hospitalizations for chronic conditions vary by county as well as state and reflect poor access to primary care as well as demographic variables. Patient safety is a function of systems, and adequate staffing. Outside of the VA system, our acute care hospitals have insufficient standards for safe and efficient performance, which compromises patient safety and outcomes. In addition, uncontrolled high prices for overuse of medical technology drives the costs of care in the U.S.

Does all this, or even the promise that it will improve as reforms are implemented, justify cutting payments to disproportionate share (DSH) hospitals, as the new law proposes? Very debatable.

However. Let's grant that the U.S. has a higher percent of poor people than other countries, that people of color are disproportionately poor, and that poorer people in the U.S. tend to be in worse health. Dr. Richard Cooper, for one, suggests that the main reason we are outspending the world on health care is that we are spending more money taking care of our poor who are sick.

To the extent that this is true, it is only possibly the case because we take care of poor people in the worst possible way - not through universal access to timely primary care, but through crisis medicine when even U.S. standards generally would not tolerate outright denials of care.

We should have fewer poor people. Race should no longer be associated with poverty. Relatively lower income should no longer determine the degree of power and control over life circumstances that are in turn associated with longevity and good health (nor for that matter should gender, sexuality, religion, or most demographic factors and lifestyle choices; age of course is the exception.). We should not only continue to document these pernicious trends, we should turn our scholarship and advocacy to redressing them. Furthermore, our health care system can contribute to social equity, and presently does poorly.

An unspoken argument is that poverty and race account not only for our higher health care spending butt also for our worse health outcomes, so it will not help to look to reforms of the health care delivery system for solutions. I don't know whether rates of medical errors or C-sections (or misuse of neonatal intensive care units) are higher in the U.S. than in, say, Finland. I know that they are higher than they should be, that they are not disproportionately prevalent in "poverty ghettos," and that they contribute to unjustifiable costs and poor outcomes. Reforming the health care delivery system should not be an excuse for failing to remedy social inequalities. Pointing to inequalities cannot divert attention from the inefficiencies and remediable deficiencies in our delivery system.

The new health reform law and ongoing HHS initiatives make reasonable efforts to acknowledge and address access, inequalities, and delivery system reforms. They won't be as successful as they could be in a single payer system like Medicare and the VA, but even a single payer system in the U.S. would have to implement the kind of delivery and organizational reforms that are now before us.

It's 2005. Three southern Pacific countries including oil-rich Bunei get together with Chile and craft a trade agreement (on the edge of your seat yet?). The "P4"do not include standard U.S. trade rules that escalate drug prices and promote smoking. They do include some weak provisions on labor and the environment.

Fast forward to June 2010. No politician in the U.S. wants to run for reelection during a job-busting depression pushing for another free trade agreement. But tobacco giant Philip Morris, U.S.-based drug companies and other corporate interests think it would be just the thing.

So the U.S. invites the "P4"- Brunei Darussalam, Chile, New Zealand and Singapore - to join up in a Trans Pacific Partnership (TPP) with the United States, Australia, Peru and Viet Nam. The second round of talks descends on San Francisco from June 14-18, aiming for a "high-quality, 21st century agreement that builds on the standards of P4, setting it up as a platform for a regional trade agreement." (The first round was in Melbourne in March; next meeting set for Brunei in October.)

With a trade agenda in flux and facing demands for a voice in trade policy from public health, labor, environmentalists and consumers, the U.S. Trade Representative invited the Center for Policy Analysis on Trade and Health (CPATH) and colleague "stakeholders" to come inside. Sort of. Here's what we found.

The week's activities raised questions about whether there may be new opportunities in this Administration for shifts in trade policy, on public health, labor, development and the environment. US staff were consistently available and insisting that the Administration wanted a new era of transparency and consultation. Further they signaled that they wanted better labor standards; they were open to concerns about tobacco control, though they also said that some members of Congress would be ready to put the brakes on.

CPATH organized a press conference on opening day, where SF Supervisor Eric Mar and public health advocates called for removing tobacco from the negotiating table. We got good coverage, as did events organized by labor and environmental groups, and PETA. (The SF Board of Supervisors passed Supv. Mar's related resolution on June 22.)

While stakeholder groups have convened at the site of trade negotiations in the past, this time we were afforded the use of facilities inside the meeting area, and the opportunity to make presentations. Highlights of the week included well-attended presentations to the delegates by CPATH, the AFL-CIO, Public Citizen, IFG and others.

CPATH's presentation to trade delegates took place on the evening before the final day of negotiations. We identified the threats to health and health care posed by uneven and unsustainable development; investor-state rules that empower corporations to bring trade charges against governments; and rules that undermine tobacco controls, access to affordable medicines, and commitments on health care and health-related services. Every delegation attended except for Vietnam. The response was overwhelmingly positive.

At the same time, the usual shroud of secrecy surrounded the details of the talks. Morning stakeholder "briefings" were held by the U.S. chief negotiator Barbara Weisel, which focused broadly on what topics were being discussed, without any information on the content. The delegates were using "bracketed text" as the basis for some of their deliberations, but the U.S. would not make this text available for us to see.

This points to a key difference in access and participation between "stakeholders" and official trade advisers; stakeholders may participate in broad discussions about topics under consideration, whereas official U.S. trade advisers review and comment on U.S. negotiating positions and actual text to be negotiated. CPATH's national Campaign for Public Health Representation has focused on bringing public health advisers onto U.S. trade advisory committees, to balance the overwhelming representation by corporate interests. HR 2293/S 1644 seek to change this imbalance legislatively.

This is the perfect time for a campaign to add Congressional co-sponsors to HR 2293/S 1644, which will in turn add public health and consumers to trade advisory committees.

Two months after it became law, many progressives are still simmering over healthcare reform, convinced that it did too much for private insurers and too little for average Americans. The stakes are high: Demagogues on the right are whipping up fear of the new law in hopes of big gains in the November elections — and counting on progressives to stay home.

It would be a tragic mistake for progressives to play into the right's hand like this. While we share the long-term goal of a universal "Medicare for all" system, too many on the left are ignoring the important improvements to access and quality of care that the new law will achieve — and the policy space that it creates to go further in the future. In particular, we believe four major myths have unduly undermined progressive enthusiasm for the new law:

Myth: Progressive activists should ignore or undermine the new law, which will get us to single payer more quickly.

Reality: An effective political movement requires both idealistic foot soldiers and politicians capable of achieving the art of the possible.

For now, this means fighting hard to protect what we’ve gained while also fighting for more on the public option, on abortion and on immigrant inclusion. Building the power to change the system involves winning victories that make a real difference in people’s lives, thus encouraging them to fight on. With healthcare reform, Democrats won a huge victory, fueled by millions of activists who need to get a pat on the back — and then get back to work. Women in particular have important reasons to stay active, including the need to defend new laws that prohibit insurance companies from discriminating against them.

It's also worth remembering that sitting out this fall's elections because of healthcare reform would mean handing control of the country back to the most extremist Republican Party in history.

Continue reading
Myth: The new law won’t save money because the insurance industry is still standing.

Reality: The law begins to address the major drivers of excess healthcare costs: the overuse and high prices of new technologies and drugs, and social and economic inequalities.

The health insurance industry is predatory, dishonest and parasitic. It contributes to unnecessary administrative complexity that drives up costs. We’d be better off without it. However, it has had the unenviable and only faintly achievable remit of negotiating with the rest of the healthcare industry, which is equally inefficient.

The new law gives us a lot to work with. We spend 16 percent of our GDP on healthcare, more than any other industrialized country, but our health outcomes are worse than most of them. Americans use fewer doctor visits and prescription drugs; we just pay much more for every procedure and every prescription. The U.S. trains more specialists, who charge more than primary care clinicians and also drive some of the inappropriate use of acute care. As a result, the U.S. experiences more hospitalizations for chronic illnesses like hypertension and diabetes — conditions that could be prevented and treated at a lower cost and with better results by appropriate primary and preventive care. And maternity care that underutilizes midwifery care frequently results in worse outcomes.

The cost-control torch ultimately needs to pass to the government, the only purchaser with sufficient countervailing power to negotiate effectively with the drug, hospital and medical device industries, and with clinicians. This is what a single-payer system would do, and the new law punts on this part. But it does use the power of Medicare and other government programs to shift toward system changes that control costs by improving quality. These changes include making comparative effectiveness research available and expanding primary care and prevention. It sets a global budget for Medicare, which must be achieved without reducing benefits or increasing costs for beneficiaries.

The other significant driver of our crummy health outcomes is the social and economic inequalities that derive from our Wild West brand of capitalism. Expanding coverage for more affordable healthcare will smooth some of these edges and improve health.

To be clear: Without a national budget of some sort, money saved through these policies will likely be shifted and spent elsewhere in the healthcare system. The pilot programs that the new law creates will provide lessons for how to improve care while reducing costs — valuable information for future reform efforts.

Myth: The insurance industry is still standing because President Obama made a backroom deal.

Reality: The president made a well-publicized deal with the entire healthcare industry, which is still a force to reckon with.

The healthcare debate revealed and reinforced important information about where power resides. Vast swaths of the U.S. are still in the grip of Republican or ConservaDem representation in Congress. Democratic campaign funding schemes bolster this arrangement by siphoning party funds from progressive to Blue Dog candidates. Progressive challengers are sprouting up in primaries around the country in response. (Bill Halter, take a bow.)

The healthcare industry accounts for one-sixth of the U.S. economy and remains enormously powerful. It includes pharmaceuticals, insurance, medical devices, hospitals and other institutions, and some groups of clinicians. Employers know that they pay less for healthcare in other countries with more equitable systems, but keeping healthcare benefits rooted in employment helps to discipline workers, who might otherwise unionize or change jobs. And more than ever, the corporate-owned, corporate-dominated media are a barrier to any meaningful population-wide comprehension of why patients and the public are being fleeced and abused, and what can be done about it.

Among the key players in the debate, on both sides, there just wasn't an appetite for major changes in how the system functions. For instance, some of the stronger unions are firmly ensconced in the same hospitals whose budgets would likely take a haircut under more substantial reform.

Remarkably, the public stuck with the issue, breathing life back into the public option time and again. As late as February, the netroots mobilized 1.2 million contacts to Congress on a single day. But no organization ever had a credible strategy for mobilizing the massive uprisings required to get rid of the insurance industry, nor did any uprising materialize spontaneously.

This left the fulcrum of power for change at the White House. Clearly, the White House calculated early on that it needed to buy all possible peace from the healthcare industry and the U.S. Chamber of Commerce. Doing so would give it time and space to nudge the issue into the public’s view long enough to establish support, before the inevitable attacks flooded the media (which they ultimately did). In the end, the administration and congressional leaders reasonably calculated that the whole enterprise could evaporate at any moment, and they didn't want to gamble on losing any votes.

Obama's reluctance to push for a bolder final law — one that included the public option, abortion and immigrant inclusion — was surprising and disappointing. But in the end, progressives should appreciate that he overcame obstacles that have sunk every reform effort over the past 100 years and managed to sign a bill into law. Now the challenge is to build on the law — to recognize the institutional changes that the law enacts, while pushing for more fundamental reform.

Myth: The country is ready to go for a Medicare-for-all single-payer system, run by the government.

Reality: The country has mixed feelings about the government. While only the public sector can truly create affordable coverage for quality care for everyone, we need to contest with corporations for the policy direction of the state.

Progressive movements in the U.S. have often battled both the government and capital. The New Deal and the Great Society marked a coda in U.S. history, characterized by aggressive activism by the federal government in the interest of the majority of the population. This heritage, perhaps now resuscitated by the Obama administration, was damaged by the “credibility gaps” of the Vietnam era, undermined by the Reagan years, and ravaged by the Bush administration.

Since 1980, the prevailing economic agenda has represented the triumph of "free" markets. The exercise of state power to defend corporate interests has been presented as a benefit to society at large: It preserves our individual freedoms and the "right" to buy an unlimited array of cheap products. In return, we are asked to consent to cuts in taxes, social services, and spending on education and health, under the pretext that it’s good for us to compete for these basic human necessities.

It is possible that within the confines of the law we just passed, a law that is both compromised and a compromise, the Obama administration intends to introduce accountability and responsiveness to the public into its healthcare policymaking. Health and Human Services Secretary Kathleen Sebelius is seeking public comment about her regulatory authority to set insurance rates. She is deciding how to define "unreasonable" rate increases and whether in fact all rates should be regulated. These are important issues that advocates and the public can and should be addressing.

Where to From Here?

With the new law, we have won policy space to further challenge corporate control, including control of the healthcare system. Limits on the insurance industry’s ability to bilk and fleece the public now include: laws; an energized public that wants to see the laws enforced; and an administration that has already taken enforcement action and gives every indication of continuing to do so. We have won major advances in coverage for healthcare and maybe for affordability.

The short- and longer-term benefits of the law could discredit the scare tactics at the center of the Republicans’ campaign to repeal the law within months. The Medicare program will not go broke at a faster rate but will be sounder financially, as will our economy overall. The misgivings expressed even by the likes of Obama supporter Merle Haggard — “I’m afraid we just can’t afford it” — should give way to the preponderance of evidence that the law will in fact reduce the deficit, once it trickles out. Many benefits will begin to roll out immediately, including lower prescription drug costs for seniors and expanded coverage for young adults. Little will change — as promised — for the overwhelming majority of Americans who are covered by self-insured or commercial health plans through large employers.

Progressives need a strategy that combines jiujitsu with direct action, and that distinguishes between necessary compromises and sellouts. We have to reach out to congressional districts currently represented by ConservaDems or Republicans and win over some of the population that straddles the middle of the road. Our culture of political debate should aim to attract and develop supporters who are savvy and well-informed to surmount the formidable obstacles we face. Progressives must move forward together. We still have the same goal: equitable, quality, universal, affordable healthcare.

Ellen R. Shaffer, Ph.D., MPH, is co-director of the Center for Policy Analysis, which sponsors the EQUAL campaign for Equitable, Quality, Universal, Affordable healthcare. Judy Norsigian is the executive director of Our Bodies, Ourselves in Boston.

Wednesday, March 24, 2010

Yay! We passed the bill! No question about it, seeing the House pass the health reform bills, and watching the President sign one of them, felt like moments of triumph. Despite our many many reservations, so many of us have worked so hard over the last year to achieve this victory! From my own work with the remarkable network that has sprung up around EQUAL, and my colleagues at KPFA; to the hard work of women's groups, progressive organizations, and public health; to the members of Congress who took on enormous obstacles: we all have a claim to this step forward. Speaker Nancy Pelosi clearly deserved major credit for working the bill through the Democratic caucus.

But there are bitter disappointments. The public option failed though it was and is popular. Reproductive rights and immigrants' rights are under assault. Corporations are gaining legal as well as de facto rights. The rabid right, while possibly diminishing and cornered, is nevertheless frightening. The opposition leadership is fanning the flames of hate, divisiveness and willful ignorance, as they experience defeat for the first time in a decade. Members of Congress are heckling each other, the President and the public. One staff member described the atmosphere as “vicious.”

It’s not all over yet, even on the most pragmatic level. The Senate will debate all week, and Republicans will attempt every possible maneuver to derail the proceedings.

Both the President and Rep. Dennis Kucinich framed the victory as one that could begin to reverse 30 years of regressive Reagan-era policies. While the details of the bill are largely technical, and far from revolutionary, one has only to think back to the tsunami of corporate opposition that buried similar proposals in the Clinton era to appreciate the potential significance of this accomplishment.

The legislation itself offers significant improvements for health coverage for many, while ducking the most far-reaching controls on costs. The immediate benefits this year include a tax credit for small businesses that offer insurance, a ban on pre-existing condition exclusions for children, the elimination of copayments for preventive care, and a $250 rebate to Medicare beneficiaries who fall into the prescription drug plan’s doughnut hole. In 2014, 16 million people will begin coverage through Medicaid (called MediCal in California), and millions more will be able to buy insurance through pools created by new state-based exchanges. The plan will limit insurance plans’ ability to gouge sick enrollees in the small group market.

The public option would be a crucial factor in controlling costs and holding insurance companies accountable. Like Medicare and other public programs, the public option was envisioned as an entity with the clout to demand lower prices from health care providers, and also a real alternative for people seeking an escape from the predatory insurance industry. Its absence leaves a gaping hole in the program’s viability.

There’s no similar dispassionate analysis of the harm inflicted on women and immigrants. At best, the bills strengthen existing prohibitions on spending federal funds on abortion and for the first time intrude on the right and ability to buy abortion coverage with private dollars; and exclude tax-paying immigrants from health benefits others enjoy. These assaults are driven purely by vitriol.

The job for progressives is to rejoice in the prospects that may be opening up, and to stay angry about what we have lost, while taking a cold, hard look at the power dynamics that landed us here. A map of the House vote suggests a huge geographically-based divide in the U.S., with representatives from the more isolated middle of the country accounting for most of the Republicans, and the 34 Democrats who voted no. Can progressives win primaries against ConservaDems in those districts? A number of organizations are chomping at the bit to find out.

We have to come up with strategies to deepen and consolidate the public’s approval of Medicare as a model for a stronger public role in the health care system, and link state based and national campaigns to pursue it.

Challenging sexism, racism and homophobia will be problematic in an era of economic recession. But our communities are organized and articulate. Winning the power to defend and advance our interests is not an option; our opponents have their knives drawn, in some cases literally.

Quoting Rep. Dennis Kucinich:
“We're at a pivotal moment in American history, and in contrast to a crippled presidency, I have to believe that this effort, however imperfect, will now have a broad positive effect on American society, and make possible many things that might not have otherwise been possible. Once this bill is signed into law, more Americans are going to be aware of this as they ask, What's in it for me? And as they become more familiar with the new law, more people will be accepting this bill. The president will have a stronger hand in domestic and international affairs, and that will be good for the country.”

Is this President up for it, and up to it? Are we? The coming months will tell.

Saturday, March 20, 2010

It's not just about the money. It's about fairness, and equality, and how profoundly our political culture is infused with the imperatives to keep us divided on the most fundamental bases. Our economic and legal systems have been engines of great progress, and also of divisions by class, race, gender, and all manner of measures of privilege and powerlessness.

It is not the same thing that anti-reform protestors on Saturday spat at Rep. Emmanuel Cleaver, and hurled a racial epithet at Rep. John Lewis, and an anti-gay slur at Barney Frank; that there is now consideration of an Executive Order strengthening even further the ban on federal funding for abortion - a life-crushing measure for millions of women - to win votes for health reform; and that the health reform package would extend no benefits to the undocumented workers who, parenthetically, pay taxes and have by and large been wrenched from their homelands by our own destruction of their domestic agricultural economies. Each of these injustices has its own history of oppression, and its heroes, heroines and triumphs.

But aren't we ready, really, to turn a tidal wave of shame and intolerance against the hate-mongers who are fanning these divisions? It's time to demand apologies, resignations, reparations, from right wing demagogues whose time-worn tactics threaten us with real harm, physical and otherwise, and attempt to keep us divided and to deflect attention from the bankruptcy of their own ideas.

Passage of the House health reform bill would be a landmark event in the march toward human justice and equality. We will no longer take it for granted that where we work should determine whether we get health care. Corporations will have to rely on their many other resources to discipline the workforce. More of us will enjoy longer and healthier lives, with greater security. The health care system itself will be constrained in its ability to penalize us for being women, for being older, for being sicker.

Let's turn our attention this Sunday not just to the vote on the House floor, but also to the march for immigrants' rights in Washington, D.C. And building on that, let's continue the momentum we began in November, 2008, to envision and implement an agenda that unites and lifts up all of us.

Monday, March 15, 2010

Let’s face it, politicians can be exasperating. Politicians who run for President get a level of exposure that would make most of us run for cover.

But Dennis Kucinich is taking a drubbing for doing what more progressives should be doing: standing up for a public option as part of the health reform bill, and demanding an ERISA amendment.

This is not a simple matter of getting the health reform bill passed. Passing a health reform bill is a bare minimum requirement for the U.S. to make progress towards an acceptable level of social justice and it should be done. Today’s “Hill” reports that the votes in play are - well, most of them. There are presently 114 Democrats declaring hesitation about the bill:

Last November, 219 Democrats voted to pass a health reform bill, 39 voted No. The bill included a public option, and also included odious provisions limiting access to abortions. Now the speaker needs 216 “yes” votes to pass a scaled back version of the bill, with fixes in the form of a budget reconciliation bill. That means she can lose 37 Democrats.

Some history
Congressman Kucinich voted for the House bill when it went through the Education and Labor Committee. That bill included a public option and an amendment he proposed to the Employee Retirement Income Security Act (ERISA), to permit states to implement single payer systems without facing a court challenge by employers.

Employers like ERISA, they like ERISA’s provisions that preempt state legislation on employment-related health care benefits, and they would be just as happy not to see any changes to it. Passing the amendment through the Committee was not an easy task, and it came about because Republican members of Congress joined some progressives to vote yes, doubtless alert to the fact this provision alone could swell Republican political contributions, and possibly sink the bill if it came before the full House. Nevertheless, the majority of the Committee voted to accept the amendment. Under normal circumstances, that would indicate it would show up in the bill that went to the House for a vote.

You didn’t see that amendment in HR 3692. That’s because in the interim the Chamber of Congress wrote to the House leadership and pledged to oppose the entire bill if it included the ERISA amendment. The House leadership crafted a bill they thought would pass, and that did not include any changes to ERISA. This was before the recent Supreme Court decision giving corporations expansive rights to influence politics. Mr. Kucinich voted “No” on the final bill.

Getting to the Public Option

Now Mr. Kucinich says he would like to discuss changing his vote to a Yes. He wants 2 things in the House bill: A public option. And the ERISA amendment.

Turns out the majority of Americans agree with him. The most popular part of the bill is the public option, and with good reason. Skeptical as we are of the government, allergic as we are to wonkitude, we have no doubt whatsoever about what lies in store for us if we have to start forking over our premiums to the private insurance industry without the option to vote with our feet. We’ll agree to pay up to get close to universal coverage. But we want a safe, affordable haven. The public option offers that, or at least the structural hope of something like that. Despite all that, we hear no end of excuses and proclamations from our elected leaders about why we can’t have it. Last week, a local health advocacy group picketed Kucinich in his district for threatening to vote No on a bill without the P.O.

Kucinich isn’t holding out for a boondoggle, or a minority vendetta. He’s staking a claim for a policy most people want. There are 114 votes in play. One of them belongs to a progressive. Let’s see about moving the other 113. Then we can come back and thank Dennis for voting Yes on a bill we actually helped to shape.

Friday, March 12, 2010

It was tempting to think that the Bush presidencies were an error from which we’ve now recovered. It’s increasingly apparent that there are deep structural fissures in our society that, like the earthquakes in Chile, have not played themselves out. Unlike that force of nature, we can do something about it – but it will take some work. Here are three tests that demand our commitment:

1. The public option. Americans want an alternative to the predatory insurance industry. They aren’t ready to mandate turning the whole apparatus of paying for health care over to the government, and we’re not going to talk them into it this year. But they damn well want a safety valve from corporate insurance.

Now, the public option is a new entity. We can predict with certainty that it will have lower administrative expenses and won’t pay profits or million dollar bonuses to executives based on denying needed care. The finer points are less certain.

But critics on the left who have consistently contended that the public option could never work seized with relish a 10-page memo dashed off by the Congressional Budget Office to House Ways and Means Chair Charles Rangel on October 29, 2009, stating that the public plan would likely enroll only about 6 million of 30 million newly covered lives. This estimate itself rested on some questionable assumptions. The House bill (in Sec. 213) tightly constrained the grounds for variation in premiums. In Sec. 322, it also limited the amount the public plan could pay to providers. Nevertheless, CBO said the public plan would have higher premiums than other plans in the new Exchanges:

That estimate of enrollment reflects CBO’s assessment that a public plan paying negotiated rates would attract a broad network of providers but would typically have premiums that are somewhat higher than the average premiums for the private plans in the exchanges.

In addition CBO stated that:

The public plan would have lower administrative costs than… private plans but would
probably engage in less management of utilization by its enrollees and attract a less healthy pool of enrollees. (The effects of that “adverse selection” on the public plan’s premiums would be only partially offset by the “risk adjustment” procedures that would apply to all plans operating in the exchanges.)

These unsubstantiated assumptions were not repeated in CBO’s extensive (167-page) examination in December, 2009, of the factors involved in speculating on the effects of possible reforms.

We need a public option. Progressives should fight as hard as we can for the most robust possible public plan. A new public entity that could enroll up to 31 million is estimable, next to 25 million in the Veterans Affairs system, 45 million in Medicare, 49 million in Medicaid, and millions more in other federal programs. It is just a step, but it is potentially a step forward.

2. Women’s rights. Abortion restrictions were voted down in the Senate, 54 – 45, scant days before Nelson bludgeoned them back in. But the House does not have a reliable pro-choice majority. The state of Utah has criminalized miscarriages if there is a claim that they are related to an attempted abortion.

I repeat: The state of Utah has criminalized miscarriages if there is a claim that they are related to an attempted abortion.

The attack on reproductive rights is not, it turn out, a side show in health reform. It is a major shot across the bow. The assault is serious, it is not going away, and progressives are going to have to fight about it, hard.

3. Single payer. Unlike the abortion issue, health reform is not a step backwards for state single payer efforts. Employers have been using ERISA (the Employee Retirement Income Security Act) for decades to block state reforms that would make them pay up for health insurance. Crusading Dennis Kucinich could still fight to get his ERISA amendment in the final bill, opening an important new avenue for states, and eliminating likely long court battles.

Happily, progressives are figuring out that if we want a progressive Congress, we need to run progressive candidates. Challengers are showing up in Democratic primaries against Bart Stupak and other pretend Dems, and organizations are springing up to support them. It will take more than the election of November, 2008, to recover from decades of neoliberal politics and corrupt economics. Passing health reform is the step we can take in the next few weeks. Fighting to make it work will be one of the projects we dig in for over the next few years.

Saturday, March 6, 2010

Writing from Santa Cruz, CA, a day after the massive one-day statewide strikes and day of action against the draconian budget cuts to public education in California - uniting teachers and school employee associations with parents and students, tartgeting cuts at every level (kindergarten - high school, community college, university) in our massively dysfunctional state. Something we haven't seen in health reform since the community-based struggles of the early 1970s. I found these excerpts from Ted Marmor's article of 2007 interesting:

Universal Health Insurance 2007: Can We Learn From the Past?
By Theodore Marmor

http://www.dissentmagazine.org/article/?article=863

Americans are not well served by their current medical care arrangements. Compared to our major trading partners and competitors, we are less likely to be insured for the cost of care, and the care that we receive is almost certain to be more costly. Although U.S. medicine has produced many “miracles,” we are not the undisputed leader in medical innovation, only in the costliness and ubiquity of high-technology medicine. Most Americans “covered” by some form of health insurance still worry about its continuation should we or a close family member become seriously ill. Some of us are locked into employment we would gladly leave but for the potential catastrophic loss of existing insurance coverage.

While most commentators decry our peculiar ability to combine insecurity with high cost, the substantial reform of American medicine at the national level has been enormously difficult to achieve, and comprehensive reform has been impossible.

There is now once again a remarkable consensus that American medical care, particularly its financing and insurance coverage, needs a major overhaul.

The bad news for reformers then and now is this: for a variety of ideological and institutional reasons, American politics makes it very difficult to coalesce around a solution that reasonably satisfies the requirements for a stable and workable system of financing and delivering modern medical care. Agreement on the seriousness of the nation’s medical ills will not necessarily generate the legislative support required for a substantively adequate and administratively workable program. That is as true in 2007 as it was in 1948, 1971, 1993, and 2000.

Before an administration and a Congress can meet the challenges of workable reform, they have to resolve—or at least cope with—some of the nastiest ideological and budgetary conflicts in American politics. As did their predecessors, they face the seemingly intractable problems of substance, symbol, and support.

The fight over Medicare illustrates the rarely achieved conditions sufficient for successful (if partial) reform. Before 1965, the conservative coalition was formidable. The Democratic landslide of 1964 swept away the key conservative bases of institutional power: dilatory tactics by the Rules Committee, control of other key committees, and a Congress as a whole less liberal than John F. Kennedy or Lyndon B. Johnson. The massive electoral shift of 1964 held a lesson for future reformers: a fully sufficient condition for reform was a two-to-one Democratic majority in the House of Representatives, a margin large enough to contain within it a (smaller) majority on Medicare.

By 1970, the debate had shifted back from Medicare to national health insurance once again. Though it is difficult for many to remember, the striking feature of the 1970–1974 years was the intense competition among proponents of different forms of universal health insurance. There was the catastrophic proposal advocated by Senators Russell Long and Abraham Ribicoff. There was the Kennedy-Corman bill that closely followed Canada’s national program as of 1971. And there was the Nixon administration’s plan for mandated health insurance for employed Americans known then as the Comprehensive Health Insurance Plan, or CHIP.

Reform failed because shifting coalitions defeated every attempt at compromise—cycling negative majorities, we might say in political science jargon. The majority that agreed on the need for reform consisted of factions committed to different proposals. The more modest proposals—such as the Long-Ribicoff catastrophic bill—seemed too limited to those who wanted to translate the negative consensus into universal, broad coverage. The proposal for employer-mandated insurance—similar in financing to what Bill Clinton later proposed—seemed too indirect, incomplete, and incapable of cost control to those favoring more straightforward forms of national health insurance. And even Ted Kennedy, who moved from his more ambitious version of national health insurance to a compromise plan that he and the powerful Wilbur Mills could both accept, was incapable of organizing a coalition of liberal and conservative Democrats.

What worked once may not, in changed circumstances, work again. What failed may succeed. But some constants in American politics are relevant.

Second, the limits of political feasibility are far less distinct than Beltway commentators seem to recognize.

Third, the role of language and emotive symbols in this policy world cannot be overestimated.

But the central lesson of the past—of both defeats and victories like Medicare—is cautionary in a different sense. It is wise to wait if what is acceptable is not workable. It is foolish to hesitate if what is workable can be made acceptable. If the central elements of a workable plan are acceptable, the pace of implementation can be staggered. But, American political history in this area shows that the opportunities for substantial reform are few and far between, precious enough to make squandering close to a sin.

Friday, February 26, 2010

First of all, kudos to Lynn Woolsey, Barbara Lee and the Progresive and Black Caucuses for presenting just the right statement on the public option; to HuffPo for giving it (and us) space; and to the 1.2 million people who stood up in one day(!) around the country yesterday for comprehensive reform. All this certainly paved the way for final statements by Murray and Pelosi on the public option.

The upshot? Obama's timeline - up to 6 weeks - to resolve all this was worrisome, if he meant to suggest this could drag on through Easter recess.

But on the whole, I think it was a careful and methodical dismemberment of every Republican argument and proposal. After both sides agreed that it was imperative to do something about the health insurance crisis, and almost 5 hours of discussion, Boehner retreated back into the standard Republican tropes and misrepresentations. It left the President sounding like the soul of reason and consideration in stating that he could not settle for a Republican plan that made no progress and would at best cover 3 million of the 45 million uninsured. He outlined places where the Democrats had already compromised (no public option, allowing insurance companies to trade across state lines, within the context of a national exchange), and offered a few weeks for the Republicans to consider if they had actual compromise proposals. But he made a firm commitment to move forward if the two sides could not agree soon. It made the reconciliation process, with a 51 vote majority, seem like a desirable process, and perhaps one the country would do well to rise up and demand.

Saturday, February 20, 2010

The public option, declared dead on a regular basis, is still supported by aboout 60% of the public, and probably a majority of Senators, who are piling on to a ststment of support initiated by Sen. Bennet of Colorado. Ask your senators to join in, or thank them if they did.

For contact numbers and a script, see the PCCC/DFA/Credo public whip count here:
http://whipcongress.com

Read the letter here:

http://whipcongress.com/letter-senate?source=med

The intention is to seek a nationally administered plan as part of the national exchange that will be available to individuals and small employers. It will be more effective if it is open to more enrolleess. Large numbers are the only way any health insurance scheme can work. As recently as December, Senator Rockefeller and others pushed for a PO that everyone could choose, including employees of large firms. This formulation did not prevail. It will have to remain on the agenda for the next round, as will single payer.

Why and how could it work? It's true that large numbers are the centerpiece of effective insurance plans.

It will likely have a higher enrollmenr than the original hastily written and brief CBO projecction, which predicted that the PO would charge higher premiums than the average plan, something that is expressly forbidden in the language of the bill itself.

Is it an attempt to put the risk of expensive cases on the public sector, while leaving the profitable business to the private sector? Death spirals - where healthy people quit and only people with expensive health conditions remain - are a problem now for publicly sponsored high risk pools, and the excuse for Anthem Blue Cross raising its rates by 39%. The difference is that the public option will be one choice for people who are all going to buy insurance anyway. Healthy individuals buying insurance are just as likely to choose the public option as a private one - probably more likely.

Where does something like this work now? While not the definitive case study, in California counties where public plans compete with private plans for enrollees in the State Children's Health Insurance Plans, the public sector does very well in enrollment and cost.

Some single payer supporters have not only retreated from support of the public option, they actively organize opposition, calling it "puny" and a plot that would destroy prospects for single payer in the future.

A great deal has been writtn about the PO, including in hours of Congressional testimony, all online. So just a few comments here:

The public option just isn't an insurance industry plot. Activists are fighting to make it a nationally administered alternative that will be as effective as possible. AHIP's opposition to the public option is a matter of public record, and their payments to the Chamber of Commere to oppose it were reported in the NY Times. If advocacy for the PO is also really an insurance industry plot, surely there would be some evidence somewhere - ?

It's not as good as a single payer, which is not attainable now. It is a placeholder that can be used and improved over time. The alternatives are no bill, or a bill without a public option.

Think about these statements, and then go look up tautology:

The public option could never work; the insurance industry will never let it work; the public option is a plot by the insurance industry to destroy the single payer movement.

You can't trust the government to do anything right; look at how the government mishandled Katrina.

Thursday, February 18, 2010

We keep hearing that people like the health reform peoposal - once they find out what it's about. EQUAL's PowerPoint offers slides you can choose from to describe:

The Problems
- Cost, Access, Quality
- Financing, Organization, Delivery
Health Care and Health
Why Insurance Doesn’t Work
The Politics of Reform
The Proposals: House and Senate
Keep Fighting for Single Payer
Fix It and Pass It!

Download it and use it - talk to your class, neighbors, friends - in the lead up to
President Obama's presentation on Feb. 25. Download it at:

Tuesday, February 2, 2010

Most people in this country would like to get the health insurance industry off their backs, given a choice.

There is an increasingly polarized clamor from the left and the right claiming that the modest but effective incremental proposals coming from Congress are leading us down the path of tyranny and corporate control.

Let’s be clear about who is controlling what.

Corporations exist to generate profits. They want them now and they don’t want a lot of guff about it. People (other than corporate executives) get to have a bit of the wealth if we fight for it. (It helps motivate us to produce and consume the goods and services that generate profits.) If corporations don’t need us any more and can figure out how to do it all with machines, they will. If they can go somewhere else where the population is under tighter political control, they will.

The government isn’t static. It protects corporations and corporate rights. It also protects people and the rights of people and communities. It can strengthen or weaken organizations (like unions) and rules that protect us. It depends on who’s in charge of the government and who is pushing them.

The Democrats’ institutional and financial base includes corporations, as well as organizations and individuals committed to limiting corporate power. Some Democrats are reliable allies. Some are not.

Corporations have an unequivocal political voice. It is the Republican party.

The last 8 years of Republican rule brought us direct cash transfers from our taxes to corporations. That’s why we have a deficit. All that money went somewhere. A lot of it went to the war industry and finance capital. The recent clamor from “independents” about the deficit is not only misdirected, it is perfectly misdirected.

We also got a wholesale incursion on our civil liberties and attacks on our rights, in the name of combating terrorism. The right now complains about a lack of debate after a year of televised hearings – on C-Span!! – while their acolytes invade town hall meetings and derail debate.

If the Republicans regain control of Congress in November, the filibuster rule will go down the drain in the first month. I shudder to think what they’ll do in the second. I’ve never lived in a fascist state, I’ve only read about it, and talked to people who have.

How can we protect our rights and challenge corporate power?

We can support laws that rein in the power of corporations to take our money and do whatever they damn well please.

The health reform bills would do that.

They establish that we Americans have the right to get health care, a principle accepted all over the rest of the world. We’re Americans so we say you have to pay in to claim the right. But the bills take a giant step in the right direction.

Not a small, insignificant step. A giant, major step.

They say that once you pay, you have to get what you paid for. The Mafia elements of the health insurance industry are under attack. Will the new laws be strong and effective enough? They could be. We have to pass them and then we have to fight to make them work. This is possible. We can do it this year. Here’s what else we would get:

1. Health care availability for most of those left out now.
2. A requirement that employers also contribute to the cost of health insurance.
3. Premium credits help make insurance affordable for incomes up to 400% of poverty.
4. A national health insurance exchange, the first step towards a national plan.
5. Coverage for comprehensive benefits
6. Ban on insurance industry abuses like pre-existing condition exclusions, rescissions
7. Payment incentives and other measures to improve the quality of care, including moving away from specialty care to preventive care to address our critical public health needs.
8. Negotiated drug prices through Medicare.

Canada had years of doctors’ strikes after passing universal coverage. But they stuck with it, fought for it, and made it work. (No, just passing the law wasn’t the end of it. They still had to fight. They still do.)

We can pass laws that strengthen the power, funding and authority of the public sector vs. the private sector. The public option would do that.

The better route would, of course, be to get corporations out of health care. Let’s talk about why no one who believes that made a serious effort in 2009 to make it happen:

We don’t have the power to do it. We don’t have the movement. It will take massive, determined grass roots mobilizations to make it happen.

The American public might get there some day. It might or might not be about health care. But we’re generally pretty healthy, and the health care system is complex and amorphous.

People are getting educated about “single payer” proposals. This is great. Some assert that the American public is already in favor of single payer, and is being restrained from achieving it because the Democrats haven’t proposed it. This is an inspiring belief. There have been about 30 people arrested nationwide in support of single payer. Maybe 100. This is a good beginning. Expanding Medicare for some or for all is a popular proposal, and we can continue to fight for it.

Is it a ruse that the corporations oppose health care reform? Not according to them. The Chamber of Commerce and American’s Health Insurance Plans joined forced to kill the pubic option. The NY Times (Jan. 31 p. 21) quotes Chamber chief R. Bruce Josten on the fact that “Despite the Democratic majorities in the House and the Senate, they have not been able to muster support for a single final bill [on health reform]. ‘We had a good year. I have no regrets.’”

Are they just fooling? Were their lobbyists all over the Committees writing the bills, just in case something passed? You bet. When they thought it was inevitable and unstoppable they were there getting their licks in. They are, perhaps, rethinking. Do they want the package to pass? No they do not.

The Democrats need to take another look at who’s voting for them and why. They need to go back and pass a bill that expands union organizing rights, as well as a jobs bill and small business tax credits. They need to go through the reconcilation process to pass a health reform bill, and they need to do it soon. They should also change the Senate rules so that they need 52 votes for cloture (or whatever number they reliably have).

Then progressives can get back to work pushing the reforms further, and mobilizing our communities to fight for our rights and our stuff. We’ll be able to do it because we’ll be living in a country that is dominated by corporations but still respects democratic rights, one that plays out daily the tensions between capital and people.

In my experience political and social change are hard, take consistent, intelligent work, strategic engagement with influential actors including the public, an analysis of where power lies, an understanding of the role and life cycles of organizations, including the ones that govern us and those that might create change. Atheist that I am, I have been impressed with my friends in the faith community. They are not health policy wonks, but they learn what they need to know, they identify their targets, they figure out what it will take to move them, and they do it. They attempt to analyze reality, engage with the reform proposals as they are and to try to influence them.

We need to pass the health reform bill, and keep the email lists and the relationships we’re building in the process. It’s going to be a bumpy few years, and we’re going to need each other.